Central Manchester University Hospitals NHS Foundation Trust v A & Ors

In deciding whether life-sustaining treatment should be withdrawn from a child lacking capacity, the court must exercise an independent and objective judgment directed solely to the child’s best interests. Best interests are assessed broadly and include medical, emotional, sensory and instinctive considerations. A strong presumption favours prolonging life, but it is not absolute and may be outweighed where treatment provides no commensurate benefit and causes significant pain or suffering. There is no legal or ethical distinction between withholding and withdrawing artificial ventilation. Each child requires separate consideration. Parental wishes, beliefs and distress are relevant only insofar as they illuminate the child’s welfare; they cannot determine the outcome. The assessment is fact-specific, particularly as to cognition, capacity to experience pleasure and the burdens of treatment.

An NHS Foundation Trust applied for declarations concerning two identical infant twins with an undiagnosed, progressive and incurable neurodegenerative disorder. Both children were dependent on mechanical ventilation and had suffered continuing neurological deterioration, pain and discomfort. Their parents opposed withdrawal, partly because of their religious beliefs and hope of future medical treatment. The children’s guardian supported the application, and independent and treating medical evidence was heard.

The central issues were whether withdrawal of ventilation, and specified limitations on further invasive treatment, would be lawful and in each child’s best interests despite the absence of parental consent.

1. Declarations granted. It was lawful and in the best interests of each child to withdraw mechanical ventilation after careful discussion with the parents about implementation. Specified forms of ventilation, resuscitation, invasive treatment and intravenous antibiotics could also be withheld in the circumstances set out in the declarations, while palliative care was provided consistently with the child’s dignity.
2. The court’s function was to make its own independent and objective decision because the children lacked capacity. The governing test was the widest assessment of best interests, requiring the court to balance all relevant benefits and burdens. The strong presumption in favour of prolonging life was important but could be outweighed where continued treatment caused suffering and conferred no commensurate benefit.
3. There was no legal or ethical distinction between withholding artificial ventilation and withdrawing it after commencement. In either case, the child’s death resulted from the underlying disorder rather than from the court or clinicians killing the child.
4. Each child required separate consideration. Although the twins’ condition was materially identical, the court had to remain alert to any difference in development, functioning or prognosis. The parents’ views and the guardian’s position required careful consideration. The parents’ own wishes, religious beliefs and the effect on the wider family were not determinative of the children’s objective best interests.
5. The decisive feature was severe and irreversible cognitive brain degeneration. Unlike the child considered in An NHS Trust v MB, the evidence showed that these children could not cognitively experience pleasure from comforting stimuli. Continued ventilation would provide physical survival only, while perpetuating pain, discomfort and treatment burdens without therapeutic purpose.

not stated in the judgment.